15 February 2011

The other day Dr Grumble exchanged emails with an American colleague. Healthcare in the US is claimed to be fantastic but they have their problems too. Dr Grumble was bemoaning the fact that the hospital managers now want Grumble to focus on money-making activity. You can understand why. The hospital needs money. And these days, now that we are in a market, there is no point in doing work that doesn't generate much of an income. Since this new system Grumble has become something of a blue-eyed boy. A new department was built. Agency staff were hired at great expense. It all paid for itself. More tests meant more money. But Grumble is also responsible for elderly patients whose main need is to be looked after well and with dignity. That doesn't pay for itself. The more you do of it the more it costs the hospital. It is not work our managers seem to want and because it is so very expensive to supply this sort of care great efforts go into paring down the staffing levels to an absolute minimum.

It's the same in the US. My American friend told me how much the interventional radiologists are now earning. It's a staggering sum. But if you look after the elderly it is quite another matter. That's the market for you. Worse, Grumble's friend told him not to bother with the elderly. Just focus on the things that make you money was his advice. That's what we do here, he wrote.

The elderly care ward certainly doesn't pay for itself. Agency staff are shunned. If you are a bit short staffed the tendency is to get by somehow. Nor are the wards as they might be. We are told that patients like to be treated with dignity. Now isn't that a surprise? So what do we do? We have red pegs on the curtains. Meanwhile elderly patients are required to crap into an equally elderly commode. The ward stinks. The commode is trundled to the sluice with faeces spilling on the way. It is no way to treat people. In the US even condemned prisoners have a loo next to their bed. And is it any wonder we have outbreaks of C diff?

Whatever system you run the elderly are always going to put a drain on resources and their care is always going to be expensive but with this new market stark differences between their care and the care of the young have been highlighted. The worried well now get their endoscopies in double-quick time because with the test comes money. If there are not enough staff the managers will offer more and more money to get those staff. If better facilities are needed they will be built. But it is not like that on the general medical ward.

Perhaps it's easier to blame 'managers' and systemic failures than it is to look further into the attitudes of the nursing, medical and social care professionals, who after all are the people in a position to recognise whether someone is malnourished or dehydrated.

How does the language used by doctors and nurses to describe their patients reflect their attitudes towards those patients?

In 2006 Harry Cayton wrote in the JRSM of the dehumanising language used by doctors and nurses to describe older patients, 'bed-blockers', 'crinklies', 'crumblies', 'geries' etc.

Still today, the British Geriatric Society tells students that:

"For a long time, geriatric medicine was the "Cinderella" specialty among both doctors and health professionals allied to medicine. As students and doctors, one will frequently hear derogatory terms applied to these patients..."

From knowing a lot of junior doctors socially over the years I think the language has far more to do with reflex self-protection, and "togetherness-in-adversity" bonding than with attitudes to patients, though there is no doubt a risk of unconsciously "labelling" the patients in unhelpful ways.

For my medical friends, aged at the time from their mid-20s to mid-30s, being a junior doctor meant being presented with a lot of death and decay on a daily basis. I dare say the same is true in nursing. It is not an easy thing for people that age to "process" - working in a very different environment, I know I didn't really begin to appreciate my own non-immortality until pushing 40. And junior docs are only a few years on from their student days, where - in common with other students - the biggest challenge might be deciding whether to get out of bed, and what to wear if you do.

Anyway, for anyone who knows junior people in general medicine, the work pressure, and the having your face rubbed in human mortality, takes quite a toll, as many junior doctor books make clear. A lot of the vocab then makes sense in the same way as the slang terms used by the army, police etc.

Coming back to the main subject, it is pretty clear to anyone who reads Nurse Anne's blog that the core operational problem is understaffing on the medical wards, which one could in turn easily trace to the kind of financial aspects Dr G highlights.

In the hospital to which I am currently attached as a medical student, I have seen horrendous treatment of the elderly.

Recently, an elderly lady was left stranded on a commode from which she was not able to leave. She was strapped on and attached to harness, incase she should fall, for over 35 minutes and during this time became extremely agitated and distressed.

I tried twice to bring this to the attention of the staff but got no where fast.

Wailing, moaning, the distress of her room partners, the callous reply from the nurses and the stench emanating throughout the ward...this isn't how health care should be done.

If this was seen to happen in a care home the consequences would be huge. A 'safeguarding adults ' investigation by social services, long meetings, possible embargo on placements by health and social services causing major economic damage to the home, staff disciplined or sacked, reported to POVA, an action plan, reported to CQC .... Hospitals, however get away scot free with this kind of thing all the time. I recently suggested that similar events should have the same consequences for the NHS as for a care home, and was met with blank astonishment by fellow commissioners.

It was the meddling of managers that created the problem. Young nurses actually need to be taught to care. In his youth Dr Grumble often witnessed ward sisters telling students nurses off for leaving patients in a pile of pooh. They would immediately clear it up themselves to demonstrate that it was a task that was too important to be left because of the need for dignity, infection control, pressure sores etc.

Dr Grumble still does the same. If a junior doctor has neglected to do a rectal examination he looks extremely disappointed, stops the whole round and does it himself. This is to demonstrated that however busy you are it makes more work not to do things when they should be done and that it is not fair to the patient. Grumble then turns to those waiting and points out with distress in his voice that the patient with diarrhoea has in fact got constipation.

There used to be much more of this sort of thing in nursing when very senior nurses taught junior nurses how to behave. This is about bad management which has led to the loss of traditional nursing hierarchical structures. And the no blame culture, while laudable in its way, has not helped.

Dr Grumble daily does ward rounds without a nurse. He sees medicines unswallowed by patients' beds. He sees water out a reach of an elderly patient. These things are daily occurrences. Some of them never ever used to happen. Certainly not the unswallowed tablets by the bed. Nursing is not what it was. Nurses cannot be less caring than they once were. It must be management changes that have brought this about.

This has been sold as an attitude problem rather than a resource problem and it seems that at least one of the posters here has fallen for that.

How can you care if you are overwhelmed with forms to fill and managers breathing down your neck to meet targets and clear beds? Not caring becomes a defence mechanism in very difficult circumstances. If you did care you wouldn't be able to do the job because you wouldn't be able to do it properly. You would just get upset. Either you grow a thick skin or find another job.

"From knowing a lot of junior doctors socially over the years I think the language has far more to do with reflex self-protection, and "togetherness-in-adversity" bonding than with attitudes to patients..."

Not sure it's really quite that simple though.

If as part of their inter-group 'bonding' sessions a group of doctors were referring to their 'n****r patient with COPD' or the 'w*g with asthma', would that be considered acceptable as the doctors need to let off steam?

Would you casually defend racist language from your wife and her colleagues as just 'self-protection' and 'adversity-in-bonding' due to the toughness of the job?

My point is that some 'isms' are apparently more institutionally acceptable than others, and it would appear that aegism is a problem in the NHS.

That is not to say that there are not structural problems that could be improved with better resourcing, staffing and financing.

But to suggest that the dehumanisation of those elderly patients highlighted in the report is all the fault of the managers and politicians seems a little simplistic. Surely the problem is multifactorial?

Great post Dr Grumble. I haven't been on a medical ward for years, except as a visitor, but I can imagine it's Hell on earth for the patients and staff. They just aren't going to generate any income and so get as little money thrown in their direction as possible.However attitudes have changed too, to care planning rather than care giving!

Last year, my mother died in hospital of cancer. The staff were kind, but clearly overstretched. One day when I was visiting, she was taken to the loo. It took over an hour to persuade someone to get her back off the loo. As she deteriorated, she was put on a bedpan in front of her husband. Both were embarrassed.

I visited my friend in hospital as she was dying. She was 29. She was left lying in her own faeces. I offered to change the sheets but was not allowed to do so. It would not have been difficult as she had anorexia and was no weight to roll over to put the sheet under her and roll her back.

I don't think that staff don't care. I do think that toiletting isn't given priority.

I was a soldier (a medic). I can crap in front of a whole platoon and it doesn't bother me. I can spend weeks covered in mess left behind on the ground by wild animals. But not everyone is ok with mess and the sick and dying should be treated with dignity and privacy.

The tariff structure certainly does what you say, but it is not immutable. It would be quite possible to alter the structure of the tariffs to reward good inpatient care, and downgrade the tariff for endoscopy. The fact that the DOH will not do this shows that the attitude problem starts at the top.

There is a devaluing of basic personal care in the Nursing structures, with this delegated to HCAs routinely. This is not just a problem of nursing staffing levels. There is also loss of continuity of nursing and medical care, with elderly patients shunted from admission ward, to outliers on surgical ward to medical ward. Previously the Houseman would have provided some continuity, but this has gone into history.

No one sees the overall slide of the patient from acute confusional state to bed bound and bedsore. Each new person coming on shift starts with the patient that they see, without the knowledge that this person was much more mobile a few days ago, and that this condition is reversible.

Doesn't matter how well intentioned staff are they all eventually burn out if things remain bad enough for long enough - this is exactly what is happening in too many parts of the NHS.

One imagines that the lot of the oldies will only get worse once the principle of market driven health care really takes hold, especially since elderly care is extremely labour intensive yet unlikely to attract much cash due to lack of productivity/profitability?

Instead of calling an ambulance every time a demented 80 year old develops pneumonia or extension of stroke how long will it be before they are kept in their nursing or own home because there is simply no more beds in the hospital to admit them to?

According to Joseph Cunningham, who investigated hospital crowding, "it is likely that hospitals with a mean bed occupancy of 90% have, at times, occupancies of over 100%, meaning that there are actually more patients than beds". http://www.publicservice.co.uk/feature_story.asp?id=10742

It's not just nurses, it's doctors numbers - as a geriatrician, I usually have about 50 patients (many quite sick and needing quite a lot done), and am supported by 2 junior doctors, often the most junior grade. Meanwhile my counterpart endocrinologist has 6 patients with 1 junior doctor for them. Those days when I first qualified, when I used to sit and talk to and really get to know the patients, are long gone.

"Dr Grumble daily does ward rounds without a nurse. He sees medicines unswallowed by patients' beds. He sees water out a reach of an elderly patient. These things are daily occurrences. Some of them never ever used to happen. Certainly not the unswallowed tablets by the bed. Nursing is not what it was. Nurses cannot be less caring than they once were. It must be management changes that have brought this about." Dr grumble comment 16th feb.

Dr. G surely this exemplifies the poor medical attitude that was a major contributor to the Mid Staffs disaster. Senior doctors turning a blind eye to poor standards of care and refusing to take their responsibility as patient advocate and leaders of the hospital service. Doctors are still the most powerful members of the hospital staff but often choose to use their power as a negative force, walking away from the problem, blaming managers. Why aren't you actively making this level of care and lack of compassion unacceptable in your wards? Better to spend time on this than on ritual rectal humiliation of junior docs at the bedside??